Provider Demographics
NPI:1194185355
Name:LORDE, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:LORDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 E 103RD ST
Mailing Address - Street 2:APT D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-2855
Mailing Address - Country:US
Mailing Address - Phone:718-257-3923
Mailing Address - Fax:
Practice Address - Street 1:740 E 103RD ST
Practice Address - Street 2:APT D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-2855
Practice Address - Country:US
Practice Address - Phone:718-257-3923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY089848104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker